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Original Contribution

Second Thoughts

November 2009

   It's about four in the morning. Jim Maple wolfs down his cereal and orange juice while his wife, Susan, rouses their three small children and gets them loaded in the family car. Jim holds down two full-time jobs. Susan drives him to the first one every day, and they have no option but to take the kids with them.

   Twenty minutes later, you, an inexperienced partner and an engine company arrive at the freeway scene of a single-vehicle rollover. It's a small SUV, like a Ford Explorer, resting on its roof. An unconscious adult male is hanging upside-down in the driver's seat, a frantic young woman is also inverted in the front passenger's seat, and there are three kids in the back. One of them is in a child seat, facing forward; the other two are also hanging from their safety belts. Inside the car everyone but the driver is crying loudly. There is little ambient light, it's raining, there's glass everywhere, steam is emerging from the engine compartment and fuel is dribbling onto the concrete from the area of the left front fender.

   The woman identifies herself as the driver's spouse. She thinks he fell asleep at the wheel, and says she herself awoke to find the vehicle sliding on the concrete and rolling onto its roof. Concerned about the fuel leak, you quickly determine that the woman and the kids are fine. You extricate them without backboards and have them moved to the ambulance's patient compartment for further assessment (and to get them out of the way). You find the driver apneic and pulseless, with his head pinned sideways (along with the shoulder strap) between the vehicle's roof and his right shoulder. Inserting a basic airway doesn't change that, and you can hear the siren from an approaching second ambulance. You triage him red, not black, and focus on him. You ask for the incoming ambulance to split their crew with you, and ask the engine company to control hazards and support the extrication.

   A few days after the call, you receive a letter from the receiving hospital's trauma coordinator. She wants to know why the passengers weren't properly extricated, and why you didn't pronounce the driver instead of tying up trauma resources. After all, he's dead.

   Q. See, this drives me crazy. Everybody's a critic. It's all so simple when you sit at a desk under fluorescent lights all day. Sometimes there just isn't time to get people packaged the way we're expected to.

   A. Well, if the trauma coordinator is just asking questions and not accusing you of anything, that's not a bad thing. We all get questioned about stuff; even trauma coordinators. It sounds to me like she's just doing her job.

   Q. Maybe, but considering our responsibilities, sometimes we need the authority to exercise some discretion. This wasn't just a routine call. In view of this family's situation, breaking the scene into two components and giving this dad a second chance seemed like a good decision at the time. You can't communicate with a bunch of screaming kids. Not to mention the fact that the weather was miserable, and we couldn't see anything.

   A. No argument here, although statistically the death of another person in the same vehicle should make you worry a little more about everybody else—especially with communication barriers.

   Q. Anybody can quote statistics. Statistics say a young guy with no cardiovascular disease would be more likely to respond to resuscitation efforts.

   A. Some people do overemphasize statistics (or manipulate them improperly). But used intelligently and honestly, they are a way for us to harness other people's experience. (By the way, many years' worth of other people's experience disagree with you about this man's likelihood of surviving.)

   Q. You can't just reduce people to statistics. This guy was a father with a young family. He was working two jobs, so they were already struggling to make it. We just had to give him a shot.

   A. Trust me, I feel for you. I do. In fact, this whole discussion was staged. I based it on my own memories of this call, its aftermath, and the questions I have been asking myself for nearly ten years. Triage can be one of the toughest things we do, and I think that's a good thing. I think it says we're keeping ourselves human, and not just following protocols.

   Thom Dick has been involved in EMS for 39 years, 23 of them as a full-time EMT and paramedic in San Diego County. He is the quality care coordinator for Platte Valley Ambulance Service, a community-owned, hospital-based 9-1-1 provider in Brighton, CO. Thom is also a member of EMS Magazine's editorial advisory board. Reach him at boxcar_414@yahoo.com.

   EMS Reruns addresses dilemmas in EMS. If you think of an example, send it to us. If we choose to publish your dilemma, we'll pay you $50. E-mail Nancy.Perry@cygnusb2b.com.

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